Rectovaginal Fistula: Causes, Symptoms, Diagnosis, Treatment and Complications

A rectovaginal fistula is an abnormal connection between the vagina and the rectum, or bottom portion of the large intestine. Gas or excrement could enter the vagina if bowel contents leak through the fistula.

Rectal fistulas may arise from:

• Injury incurred during delivery.
• Another inflammatory bowel condition, like Crohn's disease.
• Radiation therapy or cancer in the pelvic area.
• Complications after pelvic surgery.
• A side effect of diverticulitis, an inflammation of the digestive tract that affects small, projecting pouches.

The condition may cause gas and stools to leak from the vagina. This could cause you to feel uncomfortable both mentally and physically, which could have an impact on your intimacy and sense of self.

Causes ‘Of Rectovaginal Fistula

The following factors may lead to rectovaginal fistulas:

• Injuries resulting from childbirth: Injuries received during childbirth are the most common cause of rectal fistulas. An infection or a rupture that extends to the intestine in the perineum, the area of skin between the vagina and the anus are two examples of injuries. Birth trauma-related fistulas may be exacerbated by injuries to the anal sphincter, which is the muscle rings at the end of the rectum that helps hold in faeces.
• Colon irritation brought on by diarrhoea: With ulcerative colitis being less common, Crohn's disease is the second most common cause of rectovaginal fistulas. These inflammatory bowel diseases cause the tissues that line the digestive tract to swell and become inflamed. Crohn's disease raises your risk, however, the majority of persons with the illness never develop a rectovaginal fistula.
• Cancer in the pelvic area or radiation therapy: A malignant tumour in your uterus, anal canal, cervix, vagina, or rectum may be the cause of a rectovaginal fistula. Additionally, receiving radiation therapy for malignancies in specific areas may put you in danger. Although they can appear at any time following radiation therapy, radiation-induced fistulas usually do so within the first two years.
• Surgery on the vagina, anus, rectum, or perineum: Rarely, prior surgery in the lower pelvic area such as the excision of an infected Bartholin's gland may result in a fistula. Bartholin glands are located on either side of the vaginal opening and help to keep the vagina wet. A fistula may form as a result of a surgical wound, an infection, or a leak that becomes apparent later.
• An outcome of diverticulitis: Diverticulitis, an infection of the little pouches that stick out of your digestive tract and cause the large intestine or rectum to stick to the vagina, can lead to a fistula.
• Other Causes: In rare instances, skin infections around the vagina or anus may cause the development of a rectovaginal fistula.

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Symptoms Of Rectovaginal Fistula

The most common indication of a rectovaginal fistula is gas or excrement escaping from the vagina. Whether or not you experience symptoms will depend on the location and size of the fistula. On the other hand, you can be experiencing significant problems with gas leaks, stools and keeping your surroundings clean.

Diagnosis Of Rectovaginal Fistula

To diagnose a rectovaginal fistula, your doctor would likely perform a physical examination and question you about your symptoms. Your provider might suggest certain tests based on your needs.

Physical Assessment

Your doctor checks for the rectovaginal fistula during a physical examination and may rule out an infection, tumour, or abscess. The exam often involves feeling your anus, vagina, and the area between them with a gloved hand. A device designed to be inserted into a fistula may be used to locate the fistula tunnel.

Unless the fistula is very low in the vagina and visible, your healthcare provider may use a speculum to hold the walls apart so they may view inside your vagina. A proctoscope, a device that looks like a speculum, may be placed against your anus and rectum.

Your doctor may take a tiny sample of tissue for testing during the examination in the improbable scenario that they think the fistula could be the result of cancer. This is known as a biopsy. The tissue sample is sent to a lab for cell analysis.

Examinations for identifying fistulas

A rectovaginal fistula usually shows up easily on a pelvic exam. If during the examination a fistula is not found, you may require testing. If surgery is necessary, these tests can help your doctor find and examine rectovaginal fistulas and arrange the procedure.

• CT scan: An abdominal and pelvic CT scan yields more information than a standard X-ray. Using a CT scan, the location and cause of a fistula can be determined.
• MRI: Your body's soft tissues are captured in pictures by this test. An MRI can show where a fistula is, whether a tumour is present and whether other pelvic organs are involved.
• Further evaluations: You can have a colonoscopy to see inside your colon if your doctor thinks you have an inflammatory bowel disease. During the procedure, little tissue samples may be obtained for analysis in a lab. Inflammatory bowel conditions like Crohn's disease can be diagnosed using samples.
• Examine when under sedation: If more testing fails to identify a fistula, your surgeon may need to examine you in the operating room. This facilitates careful examination of the rectum and anus, which aids in the identification of the fistula and directs surgical planning.

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Treatment Of Rectovaginal Fistula

Treatment is often effective in relieving symptoms and restoring a rectovaginal fistula. The aetiology, location, size, and effect on the surrounding tissues of the fistula all influence the best course of treatment.

It is likely that after you start treatment, your surgeon will want you to wait three or six months before having surgery. This contributes to maintaining the surrounding tissue's health. Additionally, it gives the fistula time to perhaps heal itself.

An inserting seton, which is a silk or latex string, can be placed into the fistula by a surgeon to help drain any infection. This allows the tube to heal. This procedure could include surgery.

Medications

To help treat the fistula or to prepare you for surgery, your doctor may suggest any of the following drugs:

• Antibiotics: If the area around your fistula is infected, you may be recommended a course of antibiotics before surgery. Antibiotics may be recommended if you have Crohn's disease and develop a fistula.
• Infliximab: Infliximab can repair fistulas associated with Crohn's disease and reduce inflammation.

Surgery

Usually, surgery is required to close or treat a rectovaginal fistula. Before surgery, the skin and surrounding tissue the fistula should be free of irritation and infection.

The procedure to repair a fistula may be carried out by a gynaecological surgeon, a colorectal surgeon, or both working simultaneously. The goal is to excise the fistula tunnel and seal the opening by suturing the healthy tissue together.

Surgical options include:

• Removing the fistula: The fistula tunnel is removed, and the tissues of the vagina and anal regions heal.
• Using a tissue graft: The surgeon removes the fistula and creates a flap from nearby healthy tissue. The flap covers up the repair. The utilisation of muscle or tissue flaps from the vagina or rectum is one of the techniques available.
• Restoring the anal sphincter's muscles: If there is tissue injury or scarring from Crohn's disease, radiotherapy, vaginal delivery, or fistula, these muscles are repaired.
• Performing a colostomy before fistula repair in complex or recurrent cases: During a surgical procedure called a colostomy, waste is removed from your rectum through an opening in your abdomen. A colostomy may be necessary either temporarily or permanently in infrequent circumstances. Most of the time, this procedure is not required.

 A colostomy may be necessary if you have scars or tissue damage from radiation therapy, Crohn's illness, or previous surgery. You may require a colostomy if you have a recurring infection or a lot of excrement passing through the fistula.

 An abscess or malignant tumour may also require a colostomy. If a colostomy is necessary, your surgeon may decide to wait three to six months to perform it. If your doctor is confident that your fistula has healed by then, the colostomy can be reversed so that stool passes through the rectum again.

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Complications Of Rectovaginal Fistula

Rectovaginal fistula complications can include the following:

• Faecal incontinence is the term for the uncontrollably lost stool.
• Difficulties maintaining a clean perineum.
• Recurring urinary tract or vaginal infections.
• Irritation or inflammation of the skin surrounding your anus, the perineum, or your vagina.
• Return of fistula.
• Problems with intimacy and self-worth.
• Complications are common in individuals with Crohn's disease who develop a fistula. These could include delayed healing or the formation of a second fistula.

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